Chapter 22. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION

Notes Ariz. Admin. Code § R9-22-712.46

Notes Ariz. Admin. Code § R9-22-712.47

Notes Ariz. Admin. Code § R9-22-712.48

Notes Ariz. Admin. Code § R9-22-712.49

To receive appropriate reimbursement, hospitals shall: 1. Bill outpatient hospital services on the CMS approved Uniform Billing Form or in electronic format using the appropriate HIPAA transaction. 2. Follow the UB Manual Guidelines, as published by the National Uniform Billing C…

Notes Ariz. Admin. Code § R9-22-712.51

Notes Ariz. Admin. Code § R9-22-712.52

Notes Ariz. Admin. Code § R9-22-712.53

Notes Ariz. Admin. Code § R9-22-712.54

Notes Ariz. Admin. Code § R9-22-712.55

Notes Ariz. Admin. Code § R9-22-712.56

Notes Ariz. Admin. Code § R9-22-712.57

Notes Ariz. Admin. Code § R9-22-712.58

Notes Ariz. Admin. Code § R9-22-712.59

A. Inpatient hospital services with discharge dates on or after October 1, 2014, shall be reimbursed using the diagnosis related group (DRG) payment methodology described in this section and sections R9-22-712.61 through R9-22-712.81. B. Payments made using the DRG methodology sh…

A. Notwithstanding section R9-22-712.60, claims for inpatient services from the following hospitals shall be paid on a per diem basis, including provisions for outlier payments, where rates and outlier thresholds are included in the capped fee schedule published by the Administra…

A. The initial DRG base payment is the product of the DRG base rate, the DRG relative weight for the post-HCAC DRG code assigned to the claim, and any applicable provider and service policy adjustors. B. The DRG base rate for each hospital is the statewide standardized amount of …

A. Notwithstanding Section R9-22-712.62, a select specialty hospital standardized amount shall be used in place of the statewide standardized amount in subsection R9-22-712.62(B) to calculate the DRG base rate for the following hospitals: 1. Hospitals located in a city with a pop…

A. DRG Base payment: 1. For high volume out-of-state hospitals defined in subsection (C), the wage adjusted DRG base payment is determined as described in R9-22-712.62. 2. Notwithstanding subsection R9-22-712.62 the wage adjusted DRG base rate for out-of-state hospitals that are …

A. After calculating the DRG base payment as required in sections R9-22-712.62, R9-22-712.63, or R9-22-712.64, for claims from a high-utilization hospital, the product of the DRG base rate and the DRG relative weight for the post-HCAC DRG code shall be multiplied by a provider po…

In addition to subsection R9-22-712.65, for claims with DRG codes in the following categories, the product of the DRG base rate, the DRG relative weight for the post-HCAC DRG code, and the DRG provider policy adjustor shall be multiplied by the service policy adjustor listed in t…

A. For purposes of this Section a "transfer" means the transfer of a member from a hospital to a short-term general hospital for inpatient care, a designated cancer center, children's hospital, or a critical access hospital except when a member is moved for the purpose of receivi…

A. Claims for inpatient hospital services qualify for an outlier add-on payment if the claim cost exceeds the outlier cost threshold. B. The claim cost is determined by multiplying covered charges by an outlier CCR as described by the following subsections:1. For hospitals design…

Adjustments to the payments are made to account for days not covered by AHCCCS as follows: 1. A covered day reduction factor unadjusted is determined if the member is not eligible on the first day of the inpatient stay but is eligible for subsequent days during the inpatient stay…

In addition to the covered day reduction factor in R9-22-712.69, a covered day reduction factor unadjusted is determined for an inpatient stay during which an FES member receives services for the treatment of an emergency medical condition and also receives services once the cond…

A. The final DRG payment is the sum of the final DRG base payment, the final DRG outlier add-on payment, and the Differential Adjusted Payment. B. The final DRG base payment is an amount equal to the product of the covered day adjusted DRG base payment and a hospital-specific fac…

A. If a member's enrollment changes during an inpatient stay, including changing enrollment from fee-for-service to a contractor, or vice versa, or changing from one contractor to another contractor, the contractor with whom the member is enrolled on the date of discharge shall b…

If the hospital receives less than the full Medicare payment for a member eligible for benefits under Part A of Medicare because the member has exceeded the maximum benefit permitted under Part A of Medicare, the hospital shall submit a separate claim for services performed after…

DRG payments are subject to reduction based on cost avoidance under section R9-22-1003 and other rules regarding first-and third-party liability under Article 10 of this Chapter including cost avoidance for claims for ancillary services covered under Part B of Medicare. Notes Ari…

A. Categories of Administrative Days. Administrative days fall into one of two categories, either (A)(1) or (A)(2). 1. Administrative days due to lack of appropriate placement options and not meeting inpatient medical criteria. Administrative days are days in which a member is ad…

A.For inpatient stays with a length of stay greater than 29 days, a hospital may submit interim claims for each 30 day period during the inpatient stay. B.Hospitals shall be reimbursed for interim claims at a per diem rate of $500 per day. C.Following discharge, the hospital shal…

A.Except as provided for in subsection (B), for any claim for inpatient services with an admission date and discharge date that are the same calendar date, the contractor or the Administration shall process the claim as an outpatient claim and the hospital shall be reimbursed und…

If a member is readmitted without prior authorization to the same hospital that the member was discharged from within 72 hours and the DRG code assigned to the claim for the prior admission has the same first three digits as the DRG code assigned to the claim for the readmission,…

The administration shall not change any of the components of the calculation of reimbursement for inpatient services using the DRG methodology based upon a change in the hospital's ownership except to the extent those components would change under the methodology had the hospital…

A. DRG base payment for new hospitals. For any hospital that does not have a labor share or wage index published by CMS as described in section R9-22-712.62(B) because the hospital was not in operation, the DRG base rate described in section R9-22-712.62(B) shall be calculated as…

In addition to the other updates provided for in sections R9-22-712.60 through R9-22-712.80, the Administration may update the version of the APR-DRG classification system established by 3M Health Information Systems, adjust the statewide standardized amount in section R9-22-712.…

A. "Hospital-based freestanding emergency department" (hospital-based FSED) means an outpatient treatment center, as defined in R9-10-101, that: (1) provides emergency room services under R9-10-1019 , (2) is subject to the requirements of 42 C.F.R. 489.24, and (3) shares an owner…

A. If a contractor or a subcontracting provider receives an overpayment from the Administration or otherwise becomes indebted to the Administration, the contractor or subcontracting provider shall immediately remit the amount of the indebtedness or overpayment to the Administrati…

A. Provider agreement. The Administration or a contractor shall not reimburse a covered service provided to a member unless the provider has signed a provider agreement with the Administration that establishes the terms and conditions of participation and payment under A.R.S. § 3…

A.A contractor that negotiates with hospitals for inpatient or outpatient services shall reimburse hospitals for services rendered on or after March 1, 1993, as described in A.R.S. § 36-2903.01 and this Article, or at the negotiated rate that, in the aggregate, does not exceed re…

A. Definitions. The following definitions apply to this Section:1. "Contractor" has the same meaning as set forth in Arizona Revised Statutes, section 36-2901, and includes all contractors regardless of whether the GSA's served by the contractor includes urban or rural counties. …

The Administration may retain a specified percentage of capitation reimbursement to distribute to contractors based on their performance measure outcomes under A.R.S. § 36-2904. The Administration shall notify contractors 60 days prior to a new contract year if this methodology i…

A. Reinsurance is a stop-loss program provided by the Administration to a contractor for partial reimbursement of the cost of covered services for a member with an acute medical condition when the cost of covered services exceeds a pre-determined deductible level amount within a …

"Behavioral health inpatient facility" means a health care institution, other than Arizona State Hospital, that meets the following requirements: 1. Provides continuous treatment to an individual experiencing a behavioral health issue that causes the individual to:a. Have a limit…

Notes Ariz. Admin. Code § R9-22-722

Notes Ariz. Admin. Code § R9-22-723

Notes Ariz. Admin. Code § R9-22-724